David Gagan and Rosemary Gagan, For Patients of Moderate Means: A
Social History of the Voluntary Public General Hospital in Canada,
1890-1950 (Montreal and Kingston: McGill-Queen's University Press
2002)

AFTER SEVERAL DECADES of lament from Canadian medical historians
regarding the lack of an analytical history of Canadian hospital health
care, David and Rosemary Gagan have produced a timely and well-argued
survey of a major facet of this history: the rise and fall of the
secular voluntarist hospital movement. They tell the tale of the
transformation of the Canadian public general hospital, in which
19th-century medical charity was reshaped in the fires of scientific
medicine and industrial efficiency. In the late 1880s, Canadian urban
elites who were dismayed by the poor physical state of the underclass
and inspired by philanthropic zeal created charitable institutions to
nurse the indigent ill. As these institutions and their sponsoring
cities grew in size and capability, however, so too did the aspirations
of voluntarist hospital administrators and allopathic physicians.

Gagan and Gagan set the early 1920s as the point by which the
medical welfare institution was transformed into a factory to
mass-produce health care for all social classes. The charitable mandate,
though muted, was still fulfilled, as patients were reconceived as
customers whose fees produced enough profits to dispense a grudging,
no-frills, "free" service to those who could not pay. Trustees
collaborated with doctors to establish hospitals as the centre of the
medical economy, using emotional marketing campaigns to attract
customers to an expensive panoply of medical and nursing services and
promising them "All the Comforts of Home Without the Errors of
Love." (42) Along the way, doctors' grip on medical monopoly
strengthened as they negotiated the near-exclusive right to use
hospitals as their workshops and proving grounds.

In a surprisingly short time, however, in spite of the application
of industrial-sector cost-saving measures, exploitation of apprentice
nurse labour, and intensive lobbying to increase government funding, the
skyrocketing costs of hospitalization overwhelmed the resources of
"patients of moderate means," whose cash payments for private
rooms and special extras constituted the backbone of hospital revenues.
In the crucible of the Great Depression, when income from patients,
philanthropists, and municipalities dried up, and newly indigent
patients in desperate need filled admitting rooms, many public hospitals
found themselves struggling to stay afloat. This resulted, in the
authors' analysis, in a "failed vision" of accessible
hospital care that met the needs of neither patients nor doctors until
its rebirth through universal insurance initiatives beginning in the
1950s.

A key strength of the text is its usefulness in contextualizing
current dilemmas regarding health care funding and distribution. What
mission should health care institutions and medical knowledge serve in
society? Who deserves to benefit from medical expertise and technology?
Who should pay, and how much? (181) These dilemmas, the authors
demonstrate, remained unresolved through the first half of the twentieth
century, and were by no means put to rest by the advent of federal
involvement in health care. What was determined between 1890 and 1950,
as this book unequivocally shows, was the inadequacy of a health care
system that relied primarily upon philanthropic largesse, miserly governmental contributions, and revenue extracted from the already-sick
citizen. The cost of illness had to be distributed among the healthy in
order to ensure accessibility to care, a realization that inspired many
hospital authorities to lead the movement towards health insurance.

The historical evidence laid out by Gagan and Gagan also serves as
a critical reminder of the tendency for orthodox medicine and North
American society in general to invest heavily in short-term curative
technology at the expense of "medico-social,"
"alternative," and preventive services that might more
effectively address the determinants of health and quality of life.
Hospital administrators, whose spreadsheets tallied average patient
stays, per diem costs, and above all cures, envisioned the
hospital's role as "an efficient factory for the production of
scientifically mitigated health for public consumption at a fair price
commensurate with its value." (11) They strove mightily to divest
the community hospital of responsibility for all but financially
healthy, acutely ill, and quickly curable patients. Doctors, who had
little to gain financially or professionally by the practice of social
medicine or the treatment of incurables and indigents, likewise sought
to establish the hospital as a site for quick, lucrative, and
increasingly specialized procedures. The aged, the insane, and the
chronically ill, who were found disproportionately among the indigent,
were persona non grata at the "temple of science," especially
by the 1930s. (60) In the political economy of health care in the
interwar period, the modernized hospital was reserved first for persons
whose illness represented an immediate and reversible productive loss to
society, or a potential profit to health care providers; those deemed
beyond the reach of immediate medical intervention were shunted to
under-funded custodial or convalescent care, where such existed.

Gagan and Gagan approach their "social history" with the
assertion that "the social realities of the modern hospital became
a microcosm of the social structures, processes, and conditions of
everyday life." (7) In the service of this institution-as-mirror
perspective, they outline the roles and relationships of
philanthropists, administrators, physicians, nurses, and patients,
theorizing that social relations and divisions outside the hospital
shaped relations within it. For example, as the authors explain, a
highly-visible legacy of this period of Canadian hospital history was
the multi-tiered approach to patient care, in which patients were
spatially and administratively segregated according to their social
class and sometimes race. Patients from the lowest social rungs could
expect to experience similar disadvantages and discriminations inside
the hospital as they did in their daily lives. But the hospital, a
prestigious institution run by community elites and supported by local
and provincial governments, did more than passively reflect outside
social structures. Systems of segregation and regulation embedded in
hospital architecture, management, and policy (at times subverted by
individual health care providers), recreated the ideology of "less
eligibility" in the realm of health care and reinforced the notion
that social hierarchies were natural and just and fiscally necessary. If
hospital authorities imagined their institutions as guardians of
Canada's physical and economic health, they also understood it as
their public service duty to shore up the existing social order.
Superior services available for a fee reassured paying patients that
even in times of poor health their respectability and privilege would be
upheld; unsavoury public wards, means tests, and "free"
second-rate treatments reminded the indigent ill of their dependency and
of the deference owed to their benevolent betters. To summarize, Gagan
and Gagan seem to theorize segregation in the hospital primarily as a
conservative strategy to address the economic pressures caused by the
necessity for treating indigent patients. It also needs to be identified
as a manifestation of an ideology of class difference predicated upon
the idea that the needs and wants and rights of individuals differed
according to their social positioning. The significance of this
assertion is amplified as we witness the erosion of our idealistic (yet
always incomplete) universal access health system in Canada. The
neo-liberal claim that the survival of universal access demands free
market distribution of the best health care masks an ideology that
measures human worth and deservedness in economic terms.

In a history in which the built environment and workplace culture
figure so prominently, the absence of images in this book is
disappointing. Hospitals in this era produced reams of self-promotional
material, much of it in image form, commemorating or announcing various
events or public rituals. These productions were part of the deliberate
effort by hospital boards to justify the exalted place of their
institutions in the community and nation, and to sell their products and
services to individuals and governments. Moreover, the social divisions
that the authors see reflected in hospital administrative practice
appeared most strikingly in the floor plans and decor of buildings like
the ornate Private Patients Pavilion at Toronto General, or at the
Muskoka tuberculosis hospital with its private and public wards half a
mile distant from each other. The lack of photographic material is to
some extent offset by a set of statistical tables that well illustrate
many of the authors' points, and will be of considerable interest
to researchers in the field of hospital history.

All told, For Patients of Moderate Means fills an oft-stated need
for a critical survey of a key period in Canadian medical history,
synthesizing a large number of smaller studies and older literature.
Packed with detail, and drawing from a wide array of primary evidence,
the text will undoubtedly prove useful to students of medical and social
welfare history, and would serve well as an addition to public policy
reading lists.

James M. Wishart

Queen's University

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